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Laparoscopic Gastrectomy for Stomach Cancer

Approximately 22,000 people are diagnosed with gastric adenocarcinoma each year in the United States. Currently, surgical resection is the only potentially curative treatment for this patient group. When treating individuals with gastric cancer, the goal is to perform a successful oncologic resection safely while preserving patients’ quality of life. Some controversies exist regarding the treatment strategy and methods physicians use to perform the resection, particularly over the decision on whether or not laparoscopic gastrectomy is appropriate. Open gastrectomy is the most commonly used surgery in patients with resectable adenocarcinoma, but a laparoscopic approach has shown efficacy as an alternative. In fact, it may even be a preferable treatment option for select patient populations. In the April 4, 2009 Annals of Surgical Oncology, my colleagues and I compared the technical feasibility and oncologic efficacy of laparoscopic gastrectomy with open subtotal gastrectomy for gastric adenocarcinoma. As one of the largest U.S. studies of laparoscopic gastrectomy to date, our investigation demonstrated that the procedure appears to be both safe and effective. Comparing Gastrectomy Techniques In our analysis, we studied the operative characteristics and short-term oncologic and surgical outcomes of patients who underwent laparoscopic gastrectomy as compared with those who underwent open gastrectomy. Despite a longer median operative time, the minimally invasive approach was associated with the following: • Decreased length of hospital stay. • Reduced need for postoperative pain relief. • Fewer complications. • Comparable rates of recurrence-free survival after 36 months follow-up. Additionally, the short-term oncologic results yielded equivalent margin status and adequate lymph node retrieval. This is a critical aspect of cancer surgery—in order to stage patients appropriately and determine...

Getting a Grip on Asthma Control, Severity, & Exacerbations

A working group of experts from the European Respiratory Society (ERS) and the American Thoracic Society (ATS) recently published recommendations for the standardized definition and data collection for assessing asthma severity, asthma control, and asthma exacerbations in clinical trials and clinical practice (www.thoracic.org). “The FDA has traditionally required that increases in lung function (FEV1) be the primary outcome in clinical trials of new asthma therapy, but clinicians realize that the primary goals of patients are to minimize symptoms and prevent asthma attacks or exacerbations,” says Paul Enright, MD, a member of the working group. “Improved lung function is an easily available objective measure of pre-therapy asthma severity and the best test of bronchodilator therapy, but good, long-term asthma control on therapy is an even more important patient-oriented outcome.” Asthma Exacerbations According to Dr. Enright, emergency room visits for asthma indicate a failure of the healthcare system to help patients control their asthma. Asthma exacerbations occur across the spectrum of asthma severity, risk death, and cause considerable anxiety to patients and their families. They are also expensive and associated with significant loss of school days or work. Only in the past decade, however, have exacerbations been used as a primary outcome variable in research into the efficacy of drug treatment in asthma. Exacerbations should prompt changes in treatment, according to the ATS/ERS guidelines. Episodes vary considerably in speed of onset and in time to resolution, ranging from a few minutes to several weeks. They also vary in their absolute severity, both between and within individual patients. Clinical characteristics that cause acute distress and impairment in one patient may represent another...

Increasing Preventive Measures in Older Patients

Disease prevention continues to be the hallmark of good care for patients throughout their lives, not just those in their 20s, 30s, or 40s. Older adults may face a multitude of medical challenges, taking the focus away from preventive care, but it’s a physician’s job to maintain that focus for the patient’s benefit. One clear need that is not being met well is immunization against vaccine-preventable diseases like influenza and pneumococcal disease. While there has been a greater focus on influenza vaccination, there hasn’t been enough attention on the need for pneumococcal vaccination. A one-time pneumococcal inoculation can be administered at any time of the year and is recommended for every American aged 65 and older. Now is the Time Although vaccination is a relatively simple intervention, the pneumococcal immunization rate among patients aged 65 and older is suboptimal. Pneumococcal infections cause substantial morbidity and mortality. Non-invasive disease (eg, pneumonia) is dangerous, especially for older patients, but invasive disease (eg, bacteremia and meningitis) is even more problematic. The fatality rate for pneumococcal bacteremia remains 15% to 20%; for pneumococcal meningitis, it’s 16% to 37%. The rate of death is significantly higher among adults 65 and older than among younger adults. Antibiotic resistance among pneumococci further underscores the importance of prevention. The pneumococcal polysaccharide vaccine (PPSV23) is safe and effective, and a single dose can protect against approximately 75% of all invasive pneumococcal disease in adults; vaccine efficacy against non-invasive disease is not as well established. Vaccination is recommended by the CDC for all adults 65 and older, and many of these patients also have comorbidities that further increase risk,...

Psychological Intervention Improves Breast Cancer Survival

Recent research has demonstrated that stress-related psychosocial factors may be associated with the risk of recurrence and death in patients with breast cancer. Evidence has supported the use of psychological intervention programs for these patients to help them manage stress, improve health, and function more effectively. Other evidence suggests that these programs can lead to better survival rates among disease sufferers. However, past studies haven’t been designed to specifically evaluate the effect of psychological interventions on recurrence and survival rates. In the December 15, 2008 issue of Cancer, my colleagues and I published a study designed to evaluate these endpoints in patients with breast cancer who received a psychological intervention. In our investigation, over 200 newly-diagnosed patients who were surgically treated for regional breast cancer were randomized to receive a psychological intervention and assessment or only an assessment. We hypothesized that stress accompanying a cancer diagnosis may trigger psychological, behavioral, and biologic responses that are relevant to subsequent disease outcomes. An assessment of immunity was also included in the trial in order to evaluate the effects of psychological interventions on it. Currently available research evaluating the correlation between stress and cancer has focused on suppressed immune responses. The physiological link between stress and its effect on natural killer cells, however, requires further research. The Psychological Intervention The intervention used for our study in Cancer consisted of small group sessions led by clinical psychologists who discussed strategies to reduce stress, improve mood, alter health behaviors, and maintain adherence to cancer treatment and care for patients surgically treated for regional breast cancer. Patients were first educated on how stress manifested in...

Key Practices to Treating OCD

Obsessive-compulsive disorder (OCD) has been defined as a neuropsychiatric condition characterized by recurrent, distressing thoughts and repetitive behaviors or mental rituals that are performed to reduce anxiety. According to the Obsessive Compulsive Foundation, one in 50 American adults has OCD; twice that many have had it at some point in their lives. An Unrecognized Problem The Obsessive Compulsive Foundation also notes that, on average, people with OCD see three to four doctors and spend 9 years seeking treatment before they receive a correct diagnosis. It takes an average of 17 years from the time OCD begins for people to obtain appropriate treatment. “OCD tends to be underdiagnosed and undertreated for a number of reasons,” explains Jill N. Fenske, MD. “People with OCD are often secretive about their symptoms. Symptoms are often accompanied by feelings of shame because patients realize the thoughts and behaviors are excessive or unreasonable. This secrecy, along with a lack of recognition of OCD symptoms by physicians, often leads to a long delay in diagnosis and treatment.” Many primary care physicians (PCPs) and other healthcare providers are unfamiliar with OCD symptoms or are inadequately trained in the provision of appropriate treatments, adds Dr. Fenske. “OCD has a reputation of being difficult to treat, but there are many effective therapies available. As clinicians, it’s imperative to strive for an earlier diagnosis and proper treatment with the right medications or cognitive behavioral therapy (CBT) so that patients can avoid the suffering associated with OCD. A PCP can help by spotting clues regarding the presence of obsessions or compulsions.” Clinical Recommendations Dr. Fenske and Thomas L. Schwenk, MD, published...

Conference Highlights: American Academy of Orthopaedic Surgeons 2010

The American Academy of Orthopaedic Surgeons, or AAOS, held its 2010 annual meeting from March 9 to 12 in New Orleans. The features below highlight some of the news emerging from the meeting. For more information on these items and other research that was presented, go to www.aaos.org. Improving Healing After Rotator Cuff Surgery The Particulars: Rotator cuff tears are common sports injuries that lead to pain and restricted motion. Surgery to repair the damage can help reduce pain, but poor healing can still occur, leading to an incomplete recovery of function. Studies have indicated that less than 70% of rotator cuff repairs are completely healed when evaluated 2 years after surgery. Teriparatide (Forteo, Eli Lilly), an FDA-approved therapy for osteoporosis that has been shown to stimulate bone growth and slow the rate of bone loss, might enhance the healing process after rotator cuff surgery. Data Breakdown: Using a rat model, researchers performed rotator cuff surgery and then administered teriparatide injections in amounts comparable to human doses. At 2 weeks after surgery, the repair was not as strong in the rats who received teriparatide injections. However, at weeks 4 through 8, the tendon to bone interface appeared much more like normal tissue. Closer examination showed that the rats receiving teriparatide injections produced more bone and cartilage cells. The organization of the tissue was also better, more closely resembling normal tissue. The tendon was also significantly stiffer, a sign of proper healing, at 8 weeks. Take Home Pearls: Teriparatide injections appear to be a promising strategy to promote improved healing and function in patients undergoing rotator cuff surgery. The agent...

Brain Pacemakers Improve Epilepsy Treatment

According to the Epilepsy Foundation of America, epilepsy is the third leading neurological disorder, affecting more than 3 million Americans, and more than 200,000 new cases are diagnosed each year. The estimated annual cost of epilepsy is $15.5 billion in direct and indirect costs. For some patients, antiepileptic drugs (AEDs) will effectively control seizures, allowing them to lead independent lives. However, not all patients will benefit from AEDs. Nearly 1 million individuals suffer from drug-resistant epilepsy in which seizures are not controlled by drugs, or side effects of these medications are intolerable. Additionally, AEDs can be harmful if taken during pregnancy. Without effective treatment, the visible nature of epileptic seizures—muscle twitches, convulsions, massive muscle spasms, tongue-biting and staring spells, to name a few—can make it difficult for patients to live normal lives. Children find it difficult to concentrate in school, and the unpredictable nature of seizures can make extracurricular activities and bonding with peers extremely challenging. For adults, epilepsy can force patients not to drive or work, and building and maintaining relationships can be difficult. Alternative Treatments Some alternative treatments can free patients from the side effects of AEDs and allow them to enjoy greater quality of life. Some of these options include the ketogenic diet, which is high in fat and low in carbohydrates and protein. Other options include brain surgery and vagus nerve stimulation (VNS). In epilepsy surgery, a portion of a specific region in the brain thought to be causing seizures is removed. Patients are candidates for brain surgery if the source of seizures can be identified, accessed, and removed safely. VNS is much less invasive...

New Treatment Guidelines for ED

Erectile dysfunction (ED) is a common disorder of male sexual function that affects all age groups, especially older people and those with diabetes, vascular diseases, psychiatric disorders, and possibly hypogonadism. The general population continues to age and life expectancy is expected to increase. When combined with the high prevalence of diabetes and cardiovascular disease, the healthcare burden and quality-of-life issues associated with ED may be substantial. In 1995, more than 152 million men throughout the world had experienced ED, and its prevalence is predicted to reach 322 million worldwide by 2025. Furthermore, recent estimates suggest that the cost of treating ED in the United States could reach $15 billion if all affected men sought care. Current pharmacologic therapies for ED include phosphodiesterase-5 (PDE-5) inhibitors and hormonal treatment. On November 3, 2009, the American College of Physicians (ACP) published a guideline in the Annals of Internal Medicinebased on systematic reviews and current evidence, which presents recommendations on hormonal testing and pharmacologic management for ED. Initiating & Selecting Therapy The ACP strongly recommends that therapy with a PDE-5 inhibitor be initiated in men who seek treatment for ED and who do not have a contraindication for using these drugs (Figure). Oral PDE-5 inhibitors have demonstrated statistically significant and clinically relevant improvements in sexual intercourse and erectile function. Overall, PDE-5 inhibitors were well tolerated and were associated with mild or moderate adverse events. The incidence of adverse events did not significantly differ among the available PDE-5 inhibitors. Nitrate therapy, however, is a contraindication for therapy with oral PDE-5 inhibitors. The ACP also recommends that clinicians base their choices of a specific PDE-5...

American College of Cardiology 2010 Scientific Sessions

The American College of Cardiology (ACC) held its 2010 annual scientific sessions from March 14 to 16 in Atlanta. The features below highlight some of the news emerging from the ACC scientific sessions. For more information on these items and other research that was presented, go to www.acc.org. Gender Differences in Cardiac Catheterization The Particulars: In previous research data, men have been consistently more likely than women to be sent to the cardiac catheterization laboratory after noninvasive cardiovascular imaging tests. In the past, symptoms of suspected heart disease in women have often been dismissed as false positives or misinterpreted. More recently, there has been increased publicity about the underrecognition of heart disease in women, and campaigns have been launched to raise awareness. Data Breakdown: A study of 1,700 patients recruited from the Study of Myocardial Perfusion and Coronary Anatomy Imaging Roles in Coronary Artery Disease registry was conducted. Patients had no history of heart disease, presented with chest pain, and underwent cardiovascular imaging tests. Tests were abnormal in 30% of women and 22% of men. Overall, 10% of patients in the study cohort were referred to cardiac catheterization within 90 days, with higher rates in women (13%) than men (6%). Take Home Pearls: Women appear to be twice as likely as men to be referred for cardiac catheterization. Whether the difference in referrals by gender is due to excessive referrals to cardiac catheterization in women or underutilization in men requires further investigation. Promising New Data on Mitral-Clip Device The Particulars: Only about 20% of patients with significant mitral regurgitation undergo surgery, and most are managed medically. While drugs may...
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